Management of Portal Hypertension

Kulkarni, Anand V.; Rabiee, Atoosa; Mohanty, Arpan

doi:10.1016/j.jceh.2022.03.002

Cited by 21 publications

(14 citation statements)

References 156 publications

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“…SBP is a common cause of sepsis in cirrhosis [70]. NSBB, especially propranolol, has been reported to prevent SBP in patients with decompensated cirrhosis [80,81]. However, studies on NSBBs in decompensated cirrhosis are limited by small sample sizes and…”

Section: Beta-blockersmentioning

confidence: 99%

“…70 NSBB, especially propranolol, has been reported to prevent SBP in patients with decompensated cirrhosis. 80 81 However, studies on NSBBs in decompensated cirrhosis are limited by small sample sizes and heterogeneous populations. 79 Furthermore, the safety of β-blockers in patients with advanced liver disease is still questionable, given the potential consequences of reduction in cardiac output.…”

Section: Primary Preventionmentioning

confidence: 99%

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Early Diagnosis and Prevention of Infections in Cirrhosis

et al. 2022

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Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection, as well as incremental preventive strategies for infections and sepsis and consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors’ use, appropriate use of beta-blockers and vaccinations for viral diseases, including coronavirus disease-2019. Secondary prevention includes early diagnosis and timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable to improve outcomes.

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Section: Beta-blockersmentioning

confidence: 99%

Section: Primary Preventionmentioning

confidence: 99%

Early Diagnosis and Prevention of Infections in Cirrhosis

et al. 2022

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“…However, the data on these novel interventions are still evolving. Traditionally beta‐blockers are known to prevent complications of cirrhosis, including variceal bleeding, ascites, and spontaneous bacterial peritonitis, thereby prolonging survival 12,13 . A recent study also reported that propranolol could reduce ascites development in patients with compensated cirrhosis 14 .…”

Section: Introductionmentioning

confidence: 99%

“…A recent study also reported that propranolol could reduce ascites development in patients with compensated cirrhosis 14 . Nonselective beta‐blockers (NSBBs) increase intestinal transit time by blocking beta‐3 receptors and counteract altered mucosal perfusion and integrity by reducing portal pressure and intestinal permeability, further reducing endotoxemia 13,15–17 . Therefore, NSBBs can prevent endotoxemia, contain acute portal hypertension, and may prevent complications in patients with ACLF.…”

Section: Introductionmentioning

confidence: 99%

“…14 Nonselective beta-blockers (NSBBs) increase intestinal transit time by blocking beta-3 receptors and counteract altered mucosal perfusion and integrity by reducing portal pressure and intestinal permeability, further reducing endotoxemia. 13,[15][16][17] Therefore, NSBBs can prevent endotoxemia, contain acute portal hypertension, and may prevent complications in patients with ACLF. ACLF is frequently associated with kidney dysfunction, sepsis, and hypotension, questioning the safety of NSBBs in ACLF.…”

Section: Introductionmentioning

confidence: 99%

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Nonselective beta‐blockers reduce mortality in patients with acute‐on‐chronic liver failure

Kulkarni¹,

Premkumar

Kumar

et al. 2022

Portal Hypertension & Cirrhosis

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Aim Nonselective beta‐blockers (NSBBs) can reduce the incidence of complications in patients with cirrhosis and prolong survival. The safety and efficacy of NSBBs in real‐world settings in patients with acute‐on‐chronic liver failure (ACLF) identified by the Asian Pacific Association for the Study of Liver criteria are unknown. This study aimed to assess the safety and efficacy of NSBBs in patients with Asian Pacific Association for the Study of Liver (APASL)‐defined ACLF Methods In this retrospective, multicenter study, patients with ACLF with complete 30 days follow‐up from January 2019 to December 2021 were included. The primary objective was to compare 30‐day mortality among standard of care (SOC) and NSBB (+SOC) groups. The secondary objectives were to compare the incidence of infection, variceal bleed, and recompensation among both the groups. Results A total of 346 patients were included. Only 26% (n = 89) of them received NSBBs, while 74% (n = 257) received only SOC. On Kaplan–Meier analysis, the incidence of mortality was 21% (95% confidence interval [CI]: 16.20–26.50) in SOC group compared to only 8% (95% CI: 3.22–15.53) in NSBB group at Day 30 (p = 0.005). Similarly, mortality in SOC group was 63% (95% CI: 56.81–69.00) compared to 46% (95% CI: 35.44–57.00) in NSBB group at 1 year (p = 0.001). NSBB therapy could not reduce the incidence of infections or variceal bleed. Forty‐seven percent of patients in the SOC group and 73% of patients in the NSBB group (p < 0.001) recompensated. Carvedilol was prescribed in 77.5% and propranolol in 22.5% of patients. Conclusions NSBBs reduce mortality without any effect on infection or variceal bleed in patients with ACLF. However, only one in four ACLF patients are suitable for NSBB therapy.

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Standard technique in Japan for measuring hepatic venous pressure gradient

Imai,

Koizumi,

Hiasa

et al. 2024

J Gastroenterol

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Background Direct measurement of portal venous pressure (PVP) is invasive, so the hepatic venous pressure gradient (HVPG) is commonly measured to evaluate portal hypertension (PH). HVPG is the gold standard for estimating PVP but few reports have covered standardized measurement techniques. Methods This study validated standardized techniques for PVP measurement. Results In Western countries, electronic transducers are commonly used to measure PVP, whereas the water column method is still frequently applied in Japan. Setting a reference point for accurate PVP measurement is important but complicated. According to Japanese guidelines, the reference point for PVP measurement is 10 cm above the dorsal surface or in the midaxillary line. For simpler determination, the anterior axillary point, defined as the point of convergence between the proximal pectoralis major muscle and arm when both arms are positioned against the trunk in a supine position, can be used as the reference point. New methods, such as endoscopic ultrasound-guided portal pressure gradient, offer less invasive alternatives. Non-invasive methods like elastography measure liver and spleen stiffness, which correlate with HVPG. The Baveno VII criteria incorporate measurements of liver and splenic stiffness for risk stratification. Biomarkers such as type IV collagen, M2BPGi, and FIB-4 score also predict HVPG. The Baveno VII consensus emphasizes the status of HVPG as the gold standard while advocating for non-invasive alternative methods to improve patient care and monitor treatment efficacy. Conclusions Continued development of non-invasive tests is crucial for safer, more convenient PH management.

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Management of Portal Hypertension

Cited by 21 publications

References 156 publications

Early Diagnosis and Prevention of Infections in Cirrhosis

Early Diagnosis and Prevention of Infections in Cirrhosis

Nonselective beta‐blockers reduce mortality in patients with acute‐on‐chronic liver failure

Standard technique in Japan for measuring hepatic venous pressure gradient

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